151
|
Bourlière M, Pénaranda G, Adhoute X, Oules V, Castellani P. Combining non-invasive methods for assessment of liver fibrosis. ACTA ACUST UNITED AC 2008; 32:73-9. [DOI: 10.1016/s0399-8320(08)73996-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
152
|
Abstract
Prognosis and management of chronic liver diseases greatly depend on the amount and progression of liver fibrosis. Although liver biopsy is still considered as the gold standard to evaluate fibrosis in the liver, it is an invasive procedure, with rare but potentially life-threatening complications, and is prone to sampling errors. These limitations have stimulated the search for new noninvasive approaches. A number of methods, including serum indices and the measurement of liver stiffness using transient elastography, have been proposed for the noninvasive assessment of hepatic fibrosis, mainly in patients with chronic hepatitis C. It can be anticipated that these noninvasive methods will become an important tool in clinical practice in the near future. This review is aimed at discussing the advantages and limits of these methods and the perspectives for their rationale for use in clinical practice.
Collapse
Affiliation(s)
- Laurent Castera
- Service d'Hépato-Gastroentérologie, CHU Bordeaux, Hôpital Haut Lévêque, Avenue Magellan, 33604 Pessac, France.
| |
Collapse
|
153
|
Leroy V, Halfon P, Bacq Y, Boursier J, Rousselet MC, Bourlière M, de Muret A, Sturm N, Hunault G, Penaranda G, Bréchot MC, Trocme C, Calès P. Diagnostic accuracy, reproducibility and robustness of fibrosis blood tests in chronic hepatitis C: a meta-analysis with individual data. Clin Biochem 2008; 41:1368-76. [PMID: 18655779 DOI: 10.1016/j.clinbiochem.2008.06.020] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2008] [Revised: 06/18/2008] [Accepted: 06/19/2008] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To evaluate the diagnostic accuracy of liver fibrosis tests and its influencing factors in a meta-analysis with individual data. DESIGN AND METHODS Four independent centers provided four blood tests and Metavir staging from 825 patients with chronic hepatitis C. RESULTS FibroMeter AUROC (0.840) for significant fibrosis was superior to those of Fibrotest (0.803, p=0.049), APRI (0.789, p=0.001) and Hepascore (0.781, p<0.001). The misclassification rate was lower for FibroMeter (23%) than for Fibrotest and Hepascore (both 28%, p<0.001). The variation in the diagnostic cut-offs of tests among centers, reflecting the overall reproducibility, was: FibroMeter: 4.2%, APRI: 24.0%, Fibrotest: 24.2%, Hepascore: 35.0%. Accordingly, the proportion of patients diagnosed with significant fibrosis changed: FibroMeter: 0.8%, Hepascore: 2.4% (p=0.02 vs FibroMeter), Fibrotest: 5.8% (p<10(-3)), APRI: 18.2% (p<10(-3)). CONCLUSIONS This study on clinical applicability shows significant differences in diagnostic accuracy, inter-center reproducibility, and robustness of biomarkers to changes in population characteristics between blood tests.
Collapse
Affiliation(s)
- Vincent Leroy
- Clinique d'Hépato-Gastroentérologie, Pôle Digestif-DUNE, CHU, Grenoble, France.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
154
|
Ngo Y, Benhamou Y, Thibault V, Ingiliz P, Munteanu M, Lebray P, Thabut D, Morra R, Messous D, Charlotte F, Imbert-Bismut F, Rousselot-Bonnefont D, Moussalli J, Ratziu V, Poynard T. An accurate definition of the status of inactive hepatitis B virus carrier by a combination of biomarkers (FibroTest-ActiTest) and viral load. PLoS One 2008; 3:e2573. [PMID: 18596917 PMCID: PMC2440801 DOI: 10.1371/journal.pone.0002573] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 05/28/2008] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The combination of transaminases (ALT), biopsy, HBeAg and viral load have classically defined the inactive status of carriers of chronic hepatitis B. The use of FibroTest (FT) and ActiTest (AT), biomarkers of fibrosis and necroinflammatory activity, has been previously validated as alternatives to biopsy. We compared the 4-year prognostic value of combining FT-AT and viral load for a better definition of the inactive carrier status. METHODS AND FINDINGS 1,300 consecutive CHB patients who had been prospectively followed since 2001 were pre-included. The main endpoint was the absence of liver-related complications, transplantation or death. We used the manufacturers' definitions of normal FT (< = 0.27), normal AT (< = 0.29) and 3 standard classes for viral load. The adjustment factors were age, sex, HBeAg, ethnic origin, alcohol consumption, HIV-Delta-HCV co-infections and treatment. RESULTS 1,074 patients with baseline FT-AT and viral load were included: 41 years old, 47% African, 27% Asian, 26% Caucasian. At 4 years follow-up, 50 complications occurred (survival without complications 93.4%), 36 deaths occurred (survival 95.0%), including 27 related to HBV (survival 96.1%). The prognostic value of FT was higher than those of viral load or ALT when compared using area under the ROC curves [0.89 (95%CI 0.84-0.93) vs 0.64 (0.55-0.71) vs 0.53 (0.46-0.60) all P<0.001], survival curves and multivariate Cox model [regression coefficient 5.2 (3.5-6.9; P<0.001) vs 0.53 (0.15-0.92; P = 0.007) vs -0.001 (-0.003-0.000;P = 0.052)] respectively. A new definition of inactive carriers was proposed with an algorithm combining "zero" scores for FT-AT (F0 and A0) and viral load classes. This new algorithm provides a 100% negative predictive value for the prediction of liver related complications or death. Among the 275 patients with the classic definition of inactive carrier, 62 (23%) had fibrosis presumed with FT, and 3 died or had complications at 4 year. CONCLUSION In patients with chronic hepatitis B, a combination of FibroTest-ActiTest and viral load testing accurately defined the prognosis and the inactive carrier status.
Collapse
Affiliation(s)
- Yen Ngo
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | - Yves Benhamou
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | - Vincent Thibault
- Laboratoire de Virologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Patrick Ingiliz
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | | | - Pascal Lebray
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | - Dominique Thabut
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | - Rachel Morra
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | - Djamila Messous
- Fédération de Biochimie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Frederic Charlotte
- Service d'Anatomie Pathologique Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | | | | | - Joseph Moussalli
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | - Vlad Ratziu
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | - Thierry Poynard
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
- * E-mail:
| |
Collapse
|
155
|
Lambert J, Halfon P, Penaranda G, Bedossa P, Cacoub P, Carrat F. How to measure the diagnostic accuracy of noninvasive liver fibrosis indices: the area under the ROC curve revisited. Clin Chem 2008; 54:1372-8. [PMID: 18539647 DOI: 10.1373/clinchem.2007.097923] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The area under the ROC curve (AUC) is widely used to measure the diagnostic accuracy of noninvasive fibrosis indices. However, use of the AUC assumes a binary gold standard, whereas fibrosis staging is based on an ordinal scale and also depends on the distribution of fibrosis stages in the study sample. We explored other fibrosis staging accuracy measures designed for ordinal gold standards, the C-statistic and the Obuchowski measure. METHODS We performed a simulation study to assess the bias in estimating the accuracy measures when the distribution of fibrosis stages in the study sample do not fit the reference distribution in the population to which the indices are applied. We also estimated the type I error of the tests comparing these measures in 2 samples with different distributions of fibrosis stages. We illustrated the practical use of these measures by reanalyzing real data. RESULTS Compared with the AUC or the C-statistic, the Obuchowski measure showed limited bias when the distribution of fibrosis stages in the study sample differed from the reference distribution. The type I error was strongly inflated with the AUC or the C-statistic but was preserved in the Obuchowski measure. When we compared noninvasive indices on real data, AUC analysis led to discordant results depending on how the fibrosis stages were grouped together. One single conclusion was drawn from the analysis based on the Obuchowski measure. CONCLUSIONS We recommend using the Obuchowski measure for assessing the diagnostic accuracy of noninvasive indices of fibrosis.
Collapse
Affiliation(s)
- Jerome Lambert
- Université Pierre et Marie Curie-Paris; INSERM, UMR-S 707; unité de santé publique, Assistance Publique Hôpitaux de Paris, Hôpital Saint-Antoine, Paris, France
| | | | | | | | | | | |
Collapse
|
156
|
Fabris C, Smirne C, Toniutto P, Colletta C, Rapetti R, Minisini R, Falleti E, Leutner M, Pirisi M. Usefulness of six non-proprietary indirect markers of liver fibrosis in patients with chronic hepatitis C. Clin Chem Lab Med 2008; 46:253-9. [PMID: 18324909 DOI: 10.1515/cclm.2008.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The aim of the study was to perform a comprehensive diagnostic evaluation of six popular, non-proprietary, indirect markers of liver fibrosis in a cohort of patients with chronic hepatitis C representing the full spectrum of disease severity. METHODS A total of 167 consecutive, hepatitis C virus RNA positive, untreated patients with chronic hepatitis C were studied. Liver biopsy with histological evaluation and age/platelet index, aspartate aminotransferase/alanine aminotransferase ratio, aspartate aminotransferase to platelet ratio index, Bonacini's discriminant score, Forn's fibrosis index and FibroIndex were assessed in all patients. RESULTS The area under the receiver operating characteristic curves of the six tests was always greater when performed to discriminate patients with METAVIR score F4 than when assessed to discriminate patients with METAVIR score > or =F2. At step-wise discriminant analysis the only indirect marker of fibrosis entered was FibroIndex, with the following correct classification of the patients: total=52.1, patients with scores F0-F1=62.2, patients with scores F2-F3=26.0 and patients with score F4=68.4. CONCLUSIONS The ability to correctly classify patients using a panel of non-proprietary indirect markers of liver fibrosis is far from being ideal. Among them, FibroIndex appears to possess the best discriminating capacity. The simultaneous use of several indirect markers of liver fibrosis does not improve their diagnostic accuracy.
Collapse
Affiliation(s)
- Carlo Fabris
- DPMSC Medical Liver Transplantation Unit, University of Udine, Udine, Italy
| | | | | | | | | | | | | | | | | |
Collapse
|
157
|
Abstract
Transient elastography (TE, FibroScan) is a novel non-invasive method that has been proposed for the assessment of hepatic fibrosis in patients with chronic liver diseases, by measuring liver stiffness. TE is a rapid and user-friendly technique that can be easily performed at the bedside or in the outpatient clinic with immediate results and good reproducibility. Limitations include failure in around 5% of cases, mainly in obese patients. So far, TE has been mostly validated in chronic hepatitis C, with diagnostic performance equivalent to that of serum markers for the diagnosis of significant fibrosis. Combining TE with serum markers increases diagnostic accuracy and as a result, liver biopsy could be avoided for initial assessment in most patients with chronic hepatitis C. This strategy warrants further evaluation in other aetiological types of chronic liver diseases. TE appears to be an excellent tool for early detection of cirrhosis and may have prognostic value in this setting. As TE has excellent patient acceptance it could be useful for monitoring fibrosis progression and regression in the individual case, but more data are awaited for this application. Guidelines are needed for the use of TE in clinical practice.
Collapse
Affiliation(s)
- Laurent Castera
- Departments of Hepatology, Hospital Saint-André & Haut Lévêque, University Hospital of Bordeaux, Avenue Magellan, Pessac, France.
| | | | | |
Collapse
|
158
|
Abstract
Liver fibrosis is a serious health issue for many liver patients and is currently diagnosed using liver biopsy. The erroneous nature of this technique urges the search for better, noninvasive alternatives. In this regard, proteomics has been described as a useful biomarker discovery tool and has become increasingly applied in the study of liver fibrosis. Experimental and clinical studies have already provided deeper insights in the molecular pathways of liver fibrosis and even confirmed previous findings. Recent advances in proteomic strategies and tools enable multiple fractionation, multiple protein identifications and parallel analyses of multiple samples. Despite its increasing popularity, proteomics still faces certain pitfalls concerning preanalytical variability, protein coverage and statistic reliability. Proteomics is still evolving, but will undoubtedly contribute to a better understanding of the basics of the pathology and certainly offer opportunities in liver fibrosis diagnostics and therapeutics.
Collapse
|
159
|
Van Leeuwen DJ, Balabaud C, Crawford JM, Bioulac-Sage P, Dhillon AP. A clinical and histopathologic perspective on evolving noninvasive and invasive alternatives for liver biopsy. Clin Gastroenterol Hepatol 2008; 6:491-6. [PMID: 18455694 DOI: 10.1016/j.cgh.2008.02.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2007] [Revised: 01/31/2008] [Accepted: 02/04/2008] [Indexed: 02/07/2023]
Abstract
Noninvasive or minimally invasive alternatives are proposed as substitutes for liver biopsy and include clinical indices, cross-sectional imaging, serum biomarkers, liver stiffness measurement, and portal pressure measurement. Most alternatives to liver biopsy assess one aspect of liver disease and translate this into a numeric score. Overlap between categories may limit applications. Liver biopsy provides information about numerous variables: tissue architectural changes; necroinflammatory injury; fibrotic stage; alterations of parenchyma and bile duct epithelium; accumulation of fat, copper, and iron; and molecular and genetic changes. Liver biopsy may identify multiple disease etiologies. A single numeric score cannot be a substitute for complete histologic assessment. However, within defined clinical contexts, noninvasive assessment is an attractive alternative for many patients given the ease, avoidance of risk from invasive procedures, and validated contribution to clinical management. Serum biomarkers and liver stiffness assessment may become indispensable in longitudinal studies and to document outcome of treatments. The accuracy of the more reliable techniques is typically around 80%. Neither liver biopsy nor any single alternative option represents an absolute assessment of liver disease. Biopsy and alternatives are not mutually exclusive options. Liver biopsy and the noninvasive alternatives require a clear understanding of significance and limitations of each investigation. This places a responsibility on the clinician to consider fully the results of any of the investigative options used within the diagnostic and prognostic context of each individual patient, and to choose critically the most appropriate investigations for the patient's needs.
Collapse
Affiliation(s)
- Dirk J Van Leeuwen
- Section of Gastroenterology and Hepatology, Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire 03756, USA.
| | | | | | | | | |
Collapse
|
160
|
Brissot P, Troadec MB, Bardou-Jacquet E, Le Lan C, Jouanolle AM, Deugnier Y, Loréal O. Current approach to hemochromatosis. Blood Rev 2008; 22:195-210. [PMID: 18430498 DOI: 10.1016/j.blre.2008.03.001] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Iron overload diseases of genetic origin are an ever changing world, due to major advances in genetics and molecular biology. Five major categories are now established: HFE-related or type1 hemochromatosis, frequently found in Caucasians, and four rarer diseases which are type 2 (A and B) hemochromatosis (juvenile hemochromatosis), type 3 hemochromatosis (transferrin receptor 2 hemochromatosis), type 4 (A and B) hemochromatosis (ferroportin disease), and a(hypo)ceruloplasminemia. Increased duodenal iron absorption and enhanced macrophagic iron recycling, both due to an impairment of hepcidin synthesis, account for the development of cellular excess in types 1, 2, 3, and 4B hemochromatosis whereas decreased cellular iron egress is involved in the main form of type 4A) hemochromatosis and in aceruloplasminemia. Non-transferrin bound iron plays an important role in cellular iron excess and damage. The combination of magnetic resonance imaging (for diagnosing visceral iron overload) and of genetic testing has drastically reduced the need for liver biopsy. Phlebotomies remain an essential therapeutic tool but the improved understanding of the intimate mechanisms underlying these diseases paves the road for innovative therapeutic approaches.
Collapse
Affiliation(s)
- Pierre Brissot
- Liver Disease Unit, Liver Research Unit Inserm U-522, IFR 140, University of Rennes1, Hemochromatosis Reference Center, Laboratory of Molecular Genetics, University Hospital Pontchaillou, Rennes, France.
| | | | | | | | | | | | | |
Collapse
|
161
|
Lieber CS, Weiss DG, Paronetto F. Value of fibrosis markers for staging liver fibrosis in patients with precirrhotic alcoholic liver disease. Alcohol Clin Exp Res 2008; 32:1031-9. [PMID: 18422837 DOI: 10.1111/j.1530-0277.2008.00664.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Our aim was to identify markers predictive of fibrosis in alcoholic liver disease (ALD). Percutaneous liver biopsy is the recommended standard for histologic assessment of liver fibrosis. Seven serum markers (tissue inhibitor of matrix metalloproteinase 1 [TIMP1], tenascin, collagen VI, amino-terminal propeptide of type III collagen [PIIINP], matrix metalloproteinases [MMP2], laminin, and hyaluronic acid [HA]) representing various aspects of collagen and extracellular matrix deposition and degradation, have been proposed as noninvasive surrogates for liver biopsy. Moreover, a diagnostic algorithm including 3 serum markers (TIMP1, PIIINP, HA) and age has been proposed to accurately detect fibrosis with acceptable levels of sensitivity/specificity in a chronic hepatitis C subgroup. METHODS To determine variability of these markers in liver fibrosis with different etiologies, we conducted an evaluation of their correlative properties in a subgroup of patients (n = 247) with biopsy confirmed liver fibrosis resulting from long-term heavy alcohol consumption. Patients were participants in a recently completed VA multicenter clinical trial followed over 2 years with liver biopsy at baseline and 24 months, and with markers assessed every 3 months. RESULTS Among the markers measured in this alcoholic subgroup all except collagen VI displayed significant correlation with degrees of fibrosis. Three markers, TIMP1, PIIINP and HA adjusted for age, emerged as the most promising predictors of the degree of fibrosis in a population of alcoholics. However, there was little change over time as related to change in fibrosis. The lower than expected accuracy of these markers based on receiver operating curves (ROC) also showed their limited use in this etiologic subgroup. CONCLUSION In alcoholic patients, various markers have limited value in predicting and diagnosing the stages of fibrosis compared to liver biopsy. Thus, further prospective studies are required to better define the usefulness of each marker or their combination which are possibly affected by alcohol metabolism.
Collapse
Affiliation(s)
- Charles S Lieber
- James J. Peters Veterans Affairs Medical Center, Bronx, New York 10468, USA.
| | | | | | | |
Collapse
|
162
|
Friedrich-Rust M, Ong MF, Martens S, Sarrazin C, Bojunga J, Zeuzem S, Herrmann E. Performance of transient elastography for the staging of liver fibrosis: a meta-analysis. Gastroenterology 2008; 134:960-74. [PMID: 18395077 DOI: 10.1053/j.gastro.2008.01.034] [Citation(s) in RCA: 1031] [Impact Index Per Article: 64.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Accepted: 01/10/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Transient elastography has been studied in a multitude of liver diseases for the staging of liver fibrosis with variable results. A meta-analysis was performed to assess the overall performance of transient elastography for the diagnosis of liver fibrosis and to analyze factors influencing the diagnostic accuracy. METHODS Literature databases and international conference abstracts were searched. Inclusion criteria were as follows: evaluation of transient elastography, liver biopsy as reference, and assessment of the area under the receiver operating characteristic curve (AUROC). The meta-analysis was performed using the random-effects model for the AUROC, summary receiver operating curve techniques, as well as meta-regression approaches. RESULTS Fifty studies were included in the analysis. The mean AUROC for the diagnosis of significant fibrosis, severe fibrosis, and cirrhosis were 0.84 (95% confidence interval [CI], 0.82-0.86), 0.89 (95% CI, 0.88-0.91), and 0.94 (95% CI, 0.93-0.95), respectively. For the diagnosis of significant fibrosis a significant reduction of heterogeneity of the AUROC was found when differentiating between the underlying liver diseases (P < .001). Other factors influencing the AUROC were the scoring system used and the country in which the study was performed. Age, body mass index, and biopsy quality did not have a significant effect on the AUROC. CONCLUSIONS Transient elastography can be performed with excellent diagnostic accuracy and independent of the underlying liver disease for the diagnosis of cirrhosis. However, for the diagnosis of significant fibrosis, a high variation of the AUROC was found that is dependent on the underlying liver disease.
Collapse
Affiliation(s)
- Mireen Friedrich-Rust
- Department of Internal Medicine I, J. W. Goethe-University Hospital, Frankfurt, Germany
| | | | | | | | | | | | | |
Collapse
|
163
|
Biasiolo A, Chemello L, Quarta S, Cavalletto L, Bortolotti F, Caberlotto C, Beneduce L, Bernardinello E, Tono N, Fassina G, Gatta A, Pontisso P. Monitoring SCCA-IgM complexes in serum predicts liver disease progression in patients with chronic hepatitis. J Viral Hepat 2008; 15:246-9. [PMID: 18248333 DOI: 10.1111/j.1365-2893.2007.00935.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
About 30% of the patients with chronic hepatitis develop a progressive liver disease and one of the most intriguing issues is the detection of noninvasive markers for fibrosis stage and disease progression. High levels of squamous cell carcinoma antigen (SCCA)-immunoglobulin M (IgM) are detectable in hepatocellular carcinoma and their increase in cirrhotic patients can predict tumour development. As SCCA-IgM can also be detectable at low percentages in patients with chronic hepatitis, the aim of this study was to assess SCCA-IgM complexes in relation to disease outcome in this group of patients. An ELISA assay was used to determine the presence of SCCA-IgM in 188 patients with chronic hepatitis and in 100 controls. An additional serum sample was available after a median period of 6 years in 57 untreated patients: these patients were subdivided in group A, including eight patients with a fibrosis score increase > or =2 in a second liver biopsy and group B, including 49 patients without fibrosis progression during a similar follow up. SCCA-IgM complexes were detectable in 63 of 188 (33%) patients but in none of the controls. A significant increase of SCCA-IgM levels over time was observed in patients with fibrosis progression (mean +/- SD: 117 +/- 200 U/mL/year), but not in those without histologic deterioration (mean +/- SD: -8.8 +/- 31 U/mL/year, P < 0.0001). In conclusion, monitoring SCCA-IgM levels over time appears a useful approach to identify patients with chronic hepatitis at higher risk for cirrhosis development.
Collapse
Affiliation(s)
- A Biasiolo
- Clinica Medica 5, Department of Clinical and Experimental Medicine, University of Padova, Padova, Italy
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
164
|
Jarrar MH, Baranova A, Collantes R, Ranard B, Stepanova M, Bennett C, Fang Y, Elariny H, Goodman Z, Chandhoke V, Younossi ZM. Adipokines and cytokines in non-alcoholic fatty liver disease. Aliment Pharmacol Ther 2008; 27:412-21. [PMID: 18081738 DOI: 10.1111/j.1365-2036.2007.03586.x] [Citation(s) in RCA: 306] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several adipocytokines have been implicated in the pathogenesis non-alcoholic fatty liver disease (NAFLD). AIM To assess adipocytokines in NAFLD patients and controls. METHODS A total of 95 patients (26 non-alcoholic steatohepatitis (NASH), 19 simple steatosis (SS), 38 obese controls and 12 non-obese controls) were included. Fasting serum insulin, glucose, visfatin, resistin, adiponectin, tumour necrosis factor-alpha (TNF-alpha), interleukin-8 (IL-8) and IL-6 were determined. Univariate and multivariate analyses were used to compare groups and determine associations. RESULTS Serum TNF-alpha and IL-8 were higher in NAFLD patients when compared with both obese and non-obese controls. Analysis involving all patients revealed a significant correlation between serum TNF-alpha and IL-8 (P < 6.319e-08), and between IL-6 and IL-8 (P < 5.271e-15). Homeostatic model assessment scores negatively correlated with adiponectin in NAFLD (P < 0.0032). Serum visfatin was higher in all three obese groups than in non-obese controls (P < 0.02, P < 0.002 and P < 0.008). Visfatin in NASH patients was lower than SS and obese controls. Although TNF-alpha was associated with NAFLD (P < 0.02), it was interdependent on visfatin. In comparison to SS, four factors were independently associated with NASH: age, alanine aminotransferase, IL-8 and adiponectin (P < 0.05). Multivariate analysis indicated that TNF-alpha was the only independent predictor of fibrosis in NASH (P < 0.0004). CONCLUSION These findings support a complex interaction between adipocytokines and the pathogenesis of NAFLD.
Collapse
Affiliation(s)
- M H Jarrar
- Translational Research Institute, Inova Health System, Fairfax, VA, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
165
|
Romero-Gómez M, Gómez-González E, Madrazo A, Vera-Valencia M, Rodrigo L, Pérez-Alvarez R, Pérez-López R, Castellano-Megias VM, Nevado-Santos M, Alcón JC, Solá R, Pérez-Moreno JM, Navarro JM, Andrade RJ, Salmerón J, Fernández-López M, Aznar R, Diago M. Optical analysis of computed tomography images of the liver predicts fibrosis stage and distribution in chronic hepatitis C. Hepatology 2008; 47:810-6. [PMID: 18098299 DOI: 10.1002/hep.22112] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
UNLABELLED This study was undertaken to evaluate an image processing method for assessing liver fibrosis in conventional computed tomography (CT) scans in patients with chronic hepatitis C. Two cohorts (designated "estimation," n = 34; and "validation," n = 107) of chronic hepatitis C patients were assessed using digitized conventional helical CT. Weighted CT mean fibrosis (Fibro-CT) was calculated as a nonlinear weighted mean F-score for each sample. Fibrosis was defined according to Scheuer on the F0 to F4 scale by 2 pathologists blinded regarding the Fibro-CT data. Fibrosis according to Fibro-CT correlated with histology-determined fibrosis (r = 0.69; P < 0.001) and with increasing F-stage: F0 = 0.23 +/- 0.39; F1 = 0.90 +/- 0.99; F2 = 1.41 +/- 0.94; F3 = 2.79 +/- 0.55; F4 = 3.15 +/- 0.35 [analysis of variance: P < 0.0001). The receiver operating characteristics curve to diagnose significant fibrosis (>/=F2) was 0.83; 95% confidence interval (95%CI), 0.75 to 0.91; and, to diagnose advanced fibrosis (>/=F3), was 0.86, 95%CI: 0.80 to 0.93. The correlation between Fibro-CT and fibrosis was higher in patients with homogeneous distribution of fibrosis than in patients with heterogeneous distribution (r = 0.77 versus r = 0.43; P < 0.05). CONCLUSION Optical digital analysis of CT images of the liver is effective in determining the stage and distribution of liver fibrosis in chronic hepatitis C. In patients with homogeneous fibrosis distribution, the correlation between Fibro-CT and histology was better than in patients with heterogeneous distribution. Fibro-CT is a simple to use, readily available, and useful method for the diagnosis of fibrosis in patients with chronic hepatitis C.
Collapse
Affiliation(s)
- Manuel Romero-Gómez
- Unit for the Clinical Management of Digestive Diseases and CIBEREHD, Hospital Universitario de Valme, Sevilla, Spain.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
166
|
Delgado JS. Evolving trends in nonalcoholic fatty liver disease. Eur J Intern Med 2008; 19:75-82. [PMID: 18249301 DOI: 10.1016/j.ejim.2007.02.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2006] [Revised: 10/26/2006] [Accepted: 02/09/2007] [Indexed: 02/08/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is one of the most common etiologies of chronic liver disease worldwide. NALFD encompasses a continuum of histological findings ranging from steatosis alone, to nonalcoholic steatohepatitis (NASH) with steatosis, inflammation, hepatocyte ballooning, fibrosis and eventually liver cirrhosis. The pathogenesis of NAFLD might be related to a deregulated cross-talk between liver and visceral adipose tissue, originating an impairment of normal insulin signaling. A better comprehension of the immunologic and metabolic roles of adipose tissue in modulating inflammatory pathways will enhance our understanding of the molecular mechanisms leading to progression of fatty liver disease. These insights, moreover, will suggest new strategies to improve insulin sensitivity and reduce obesity-associated morbidities and mortality.
Collapse
Affiliation(s)
- Jorge-Shmuel Delgado
- The University of Chicago, Section of Gastroenterology, Department of Medicine, Chicago, 5841 S. Maryland Ave., MC 4076 Chicago, IL 60637, USA.
| |
Collapse
|
167
|
Sebastiani G, Vario A, Guido M, Alberti A. Performance of noninvasive markers for liver fibrosis is reduced in chronic hepatitis C with normal transaminases. J Viral Hepat 2008; 15:212-8. [PMID: 18179453 DOI: 10.1111/j.1365-2893.2007.00932.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
In chronic hepatitis C, biopsy is the gold standard for assessment of liver fibrosis. Few studies investigated noninvasive markers of liver fibrosis in hepatitis C virus (HCV) patients with normal alanine aminotrasferase (NALT). Eighty HCV patients with NALT and 164 HCV patients with elevated alanine aminotrasferase (EALT) who underwent a diagnostic liver biopsy were evaluated for AST-to-platelet ratio, Forns' index, AST-to-ALT ratio (AAR), Fibrotest and the recently proposed Fibroindex, using liver histology as reference standard. The primary end-point was the detection of significant fibrosis (> or =F2). Performance of noninvasive markers was expressed as specificity, sensitivity and positive (PPV) and negative (NPV) predictive value, accuracy and area under the receiver operating characteristic curve (AUROC). All noninvasive markers for liver fibrosis tested showed a poorer performance in NALT group than in EALT group. Overall, Fibrotest had the best performance in NALT group, as showed by AUROC of 0.70 and 73.5% accuracy. Performance of AAR, Forns' index and Fibroindex was poor in NALT group and it was significantly lower than in EALT group for Forns and Fibroindex (AUROC 0.6 vs 0.76 and 0.58 vs 0.74, respectively, P = 0.05). In NALT patients, PPV was high for all noninvasive markers (>87%) except for AAR, while NPV was low (<65%), thus none of them was able to reliably exclude significant fibrosis. In conclusion, performance of noninvasive-markers is significantly reduced in HCV patients with NALT. Liver biopsy may still be needed for many of these cases to correctly stage liver fibrosis. Specific noninvasive tools and possibly combination of markers should be developed and validated in this clinical setting.
Collapse
Affiliation(s)
- G Sebastiani
- Venetian Institute of Molecular Medicine, Padova, Italy
| | | | | | | |
Collapse
|
168
|
Gressner OA, Weiskirchen R, Gressner AM. Biomarkers of hepatic fibrosis, fibrogenesis and genetic pre-disposition pending between fiction and reality. J Cell Mol Med 2008; 11:1031-51. [PMID: 17979881 PMCID: PMC4401271 DOI: 10.1111/j.1582-4934.2007.00092.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Fibrosis is a frequent, life-threatening complication of most chronic liver diseases. Despite major achievements in the understanding of its pathogenesis, the translation of this knowledge into clinical practice is still limited. In particular, non-invasive and reliable (serum-) biomarkers indicating the activity of fibrogenesis are scarce. Class I biomarkers are defined as serum components having a direct relation to the mechanism of fibrogenesis, either as secreted matrix-related components of activated hepatic stellate cells and fibroblasts or as mediators of extracellular matrix (ECM) synthesis or turnover. They reflect primarily the activity of the fibrogenic process. Many of them, however, proved to be disappointing with regard to sensitivity and speci-ficity. Up to now hyaluronan turned out to be the relative best type I serum marker. Class II biomarkers comprise in general rather simple standard laboratory tests, which are grouped into panels. They fulfil most criteria for detection and staging of fibrosis and to a lesser extent grading of fibrogenic activity. More than 20 scores are currently available, among which Fibrotest™ is the most popular one. However, the diagnostic use of many of these scores is still limited and standardization of the assays is only partially realized. Combining of panel markers in sequential algorithms might increase their diagnostic validity. The translation of genetic pre-disposition biomarkers into clinical practice has not yet started, but some polymorphisms indicate a link to progression and outcome of fibrogenesis. Parallel to serum markers non-invasive physical techniques, for example, transient elastography, are developed, which can be combined with serum tests and profiling of serum proteins and glycans.
Collapse
Affiliation(s)
- O A Gressner
- Institute of Clinical Chemistry and Pathobiochemistry, Central Laboratory, RWTH-University Hospital, Aachen, Germany.
| | | | | |
Collapse
|
169
|
Talwalkar JA, Yin M, Fidler JL, Sanderson SO, Kamath PS, Ehman RL. Magnetic resonance imaging of hepatic fibrosis: emerging clinical applications. Hepatology 2008; 47:332-42. [PMID: 18161879 DOI: 10.1002/hep.21972] [Citation(s) in RCA: 262] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Chronic liver disease and cirrhosis remains a major public health problem worldwide. While the majority of complications from chronic liver disease result from progressive hepatic fibrosis, the available diagnostic tests used in clinical practice are not sensitive or specific enough to detect occult liver injury at early or intermediate stages. While liver biopsy can stage the extent of fibrosis at diagnosis, its utility as a tool for longitudinal monitoring will be limited at the population level. To date, a number of methods including serum marker panels and ultrasound-based transient elastrography have been proposed for the non-invasive identification of hepatic fibrosis. Novel techniques including magnetic resonance (MR) spectroscopy, diffusion weighted MR, and MR elastography have also emerged for detecting fibrosis. In contrast to other non-invasive methods, MR imaging holds the promise of providing functional and biological information about hepatic pathophysiology as it relates to the natural history and future treatment of hepatic fibrosis. (HEPATOLOGY 2007.).
Collapse
Affiliation(s)
- Jayant A Talwalkar
- Advanced Liver Diseases Study Group, Miles and Shirley Fitterman Center for Digestive Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA.
| | | | | | | | | | | |
Collapse
|
170
|
Shaheen AAM, Wan AF, Myers RP. FibroTest and FibroScan for the prediction of hepatitis C-related fibrosis: a systematic review of diagnostic test accuracy. Am J Gastroenterol 2007; 102:2589-600. [PMID: 17850410 DOI: 10.1111/j.1572-0241.2007.01466.x] [Citation(s) in RCA: 259] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The accurate diagnosis of hepatitis C virus (HCV)-related fibrosis is crucial for prognostication and treatment decisions. Due to the limitations of biopsy, noninvasive alternatives including FibroTest and FibroScan have been developed. Our objective was to systematically review studies describing the accuracy of these tests for predicting HCV-related fibrosis. METHODS Studies comparing FibroTest or FibroScan versus biopsy in HCV patients were identified via an electronic search. Random effects meta-analyses and areas under summary receiver operating characteristics curves (AUC) were examined to characterize test accuracy for significant fibrosis (F2-4) and cirrhosis. Heterogeneity was explored using meta-regression. RESULTS Twelve studies were identified, 9 for FibroTest (N = 1,679) and 4 for FibroScan (N = 546). In heterogeneous analyses for significant fibrosis, the AUCs for FibroTest and FibroScan were 0.81 (95% CI 0.78-84) and 0.83 (0.03-1.00), respectively. At a threshold of approximately 0.60, the sensitivity and specificity of the FibroTest were 47% (35-59%) and 90% (87-92%). For FibroScan (threshold approximately 8 kPa), corresponding values were 64% (50-76%) and 87% (80-91%), respectively. Methodological quality, the length of liver biopsy specimens, and inclusion of special populations did not explain the observed heterogeneity. However, the diagnostic accuracy of both measures was associated with the prevalence of significant fibrosis and cirrhosis in the study populations. For cirrhosis, the summary AUCs for FibroTest and FibroScan were 0.90 (95% CI not calculable) and 0.95 (0.87-0.99), respectively. CONCLUSIONS FibroTest and FibroScan have excellent utility for the identification of HCV-related cirrhosis, but lesser accuracy for earlier stages. Refinements are necessary before these tests can replace liver biopsy.
Collapse
Affiliation(s)
- Abdel Aziz M Shaheen
- Liver Unit, Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | | |
Collapse
|
171
|
Poynard T, Morra R, Halfon P, Castera L, Ratziu V, Imbert-Bismut F, Naveau S, Thabut D, Lebrec D, Zoulim F, Bourliere M, Cacoub P, Messous D, Munteanu M, de Ledinghen V. Meta-analyses of FibroTest diagnostic value in chronic liver disease. BMC Gastroenterol 2007; 7:40. [PMID: 17937811 PMCID: PMC2175505 DOI: 10.1186/1471-230x-7-40] [Citation(s) in RCA: 216] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2007] [Accepted: 10/15/2007] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND FibroTest (FT) is a biomarker of liver fibrosis initially validated in patients with chronic hepatitis C (CHC). The aim was to test two hypotheses, one, that the FT diagnostic value was similar in the three other frequent fibrotic diseases: chronic hepatitis B (CHB), alcoholic liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD); and the other, that the FT diagnostic value was similar for intermediate and extreme fibrosis stages. METHODS The main end points were the FT area under the ROC curves (AUROCs) for the diagnosis of bridging fibrosis (F2F3F4 vs. F0F1), standardized for the spectrum of fibrosis stages, and the comparison of FT AUROCs between adjacent stages. Two meta-analyses were performed: one combining all the published studies (random model), and one of an integrated data base combining individual data. Sensitivity analysis integrated the independency of authors, lenght of biopsy, prospective design, respect of procedures, comorbidities, and duration between biopsy and serum sampling. RESULTS A total of 30 studies were included which pooled 6,378 subjects with both FT and biopsy (3,501 HCV, 1,457 HBV, 267 NAFLD, 429 ALD, and 724 mixed). Individual data were analyzed in 3,282 patients. The mean standardized AUROC was 0.84 (95% CI, 0.83-0.86), without differences between causes of liver disease: HCV 0.85 (0.82-0.87), HBV 0.80 (0.77-0.84), NAFLD 0.84 (0.76-0.92), ALD 0.86 (0.80-0.92), mixed 0.85 (0.80-0.93). The AUROC for the diagnosis of the intermediate adjacent stages F2 vs. F1 (0.66; 0.63-0.68, n = 2,055) did not differ from that of the extreme stages F3 vs. F4 (0.69; 0.65-0.72, n = 817) or F1 vs. F0 (0.62; 0.59-0.65, n = 1788). CONCLUSION FibroTest is an effective alternative to biopsy in patients with chronic hepatitis C and B, ALD and NAFLD. The FT diagnostic value is similar for the diagnosis of intermediate and extreme fibrosis stages.
Collapse
Affiliation(s)
- Thierry Poynard
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS ESA 8067 Paris, France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
172
|
Morra R, Munteanu M, Imbert-Bismut F, Messous D, Ratziu V, Poynard T. FibroMAX: towards a new universal biomarker of liver disease? Expert Rev Mol Diagn 2007; 7:481-90. [PMID: 17892356 DOI: 10.1586/14737159.7.5.481] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Among the noninvasive alternatives to liver biopsy, several studies have demonstrated the predictive value and a better benefit-to-risk ratio than biopsy of five combinations of simple serum biochemical markers (the super combination being FibroMAX (BioPredictive, Paris, France) in patients at risk of chronic liver diseases: FibroTest (BioPredictive) for the quantitative assessment of fibrosis; SteatoTest (BioPredictive) for the quantitative assessment of steatosis; ActiTest (BioPredictive) for the quantitative assessment of necroinflammatory activity in chronic viral hepatitis C and B; NashTest (BioPredictive) for the categorical diagnosis of nonalcoholic steatohepatitis; and AshTest for the quantitative assessment of alcoholic steatohepatitis (also known in the USA as HCV-FibroSURE, HBV-FibroSURE, ASH-FibroSURE and NASH-FibroSURE; LabCorp, NC, USA). The possible causes of false-negative and false-positive results are also better identified. These tests, which are now available in 50 countries, can facilitate the screening and management of the most frequent liver diseases.
Collapse
Affiliation(s)
- Rachel Morra
- Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75651 Paris Cedex 13, France.
| | | | | | | | | | | |
Collapse
|
173
|
Shaheen AAM, Myers RP. Diagnostic accuracy of the aspartate aminotransferase-to-platelet ratio index for the prediction of hepatitis C-related fibrosis: a systematic review. Hepatology 2007; 46:912-21. [PMID: 17705266 DOI: 10.1002/hep.21835] [Citation(s) in RCA: 280] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
UNLABELLED The development of noninvasive markers of liver fibrosis is a clinical and research priority. The aspartate aminotransferase-to-platelet ratio index (APRI) is a promising tool with limited expense and widespread availability. Our objective was to systematically review the performance of the APRI in hepatitis C virus (HCV)-infected patients. Random effects meta-analyses and areas under summary receiver operating characteristic curves (AUC) were examined to characterize APRI accuracy for significant fibrosis (stages 2-4) and cirrhosis. In 22 studies (n = 4,266), the summary AUCs of the APRI for significant fibrosis and cirrhosis were 0.76 [95% confidence interval (CI), 0.74-0.79] and 0.82 (95%CI, 0.79-0.86), respectively. For significant fibrosis, an APRI threshold of 0.5 was 81% sensitive and 50% specific. At a 40% prevalence of significant fibrosis, this threshold had a negative predictive value (NPV) of 80%, but could reduce the necessity of liver biopsy by only 35%. For cirrhosis, a threshold of 1.0 was 76% sensitive and 71% specific. At a 15% cirrhosis prevalence, the NPV of this threshold was 91%. Higher APRI thresholds had suboptimal positive predictive values except in settings with a high prevalence of cirrhosis. APRI accuracy was not affected by the prevalence of advanced fibrosis, or study and biopsy quality. However, the accuracy for cirrhosis was greater in studies including human immunodeficiency virus (HIV)/HCV-co-infected patients. CONCLUSION The major strength of the APRI is the exclusion of significant HCV-related fibrosis. Future studies of novel markers should demonstrate improved accuracy and cost-effectiveness compared with this economical and widely available index.
Collapse
Affiliation(s)
- Abdel Aziz M Shaheen
- Liver Unit, Division of Gastroenterology, Department of Medicine; University of Calgary, Calgary, Alberta, Canada
| | | |
Collapse
|
174
|
Calès P, Veillon P, Konaté A, Mathieu E, Ternisien C, Chevailler A, Godon A, Gallois Y, Joubaud F, Hubert-Fouchard I, Oberti F, Réaud S, Hunault G, Mauriat F, Lunel-Fabiani F. Reproducibility of blood tests of liver fibrosis in clinical practice. Clin Biochem 2007; 41:10-8. [PMID: 17988658 DOI: 10.1016/j.clinbiochem.2007.08.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2007] [Revised: 07/13/2007] [Accepted: 08/09/2007] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To evaluate the inter-laboratory reproducibility of blood test for liver fibrosis: FibroMeter, Fibrotest, APRI and their composites variables. DESIGN AND METHODS Four studies, including 147 patients, were performed: study #1 included 2 metachronous blood samples and 2 laboratories; studies #2, #3 and #4 included synchronous samples with assays delayed at day 1 in 12 laboratories, at day 0 in 10 laboratories and at day 0 or 1 in 2 laboratories, respectively. Agreement was evaluated by the intraclass correlation coefficient (r(ic)). RESULTS In studies #1, #2 and #4, r(ic) for FibroMeter was 0.893, 0.942 and 0.991, respectively. In study #3, the r(ic) were: FibroMeter: 0.963, Fibrotest: 0.984, APRI: 0.949. Large simulated variations in composite variables had a weak impact on FibroMeter. CONCLUSIONS When blood marker limits are controlled, inter-laboratory agreement of blood tests is excellent in clinical practice conditions. Blood tests are robust against the variability of composite blood variables.
Collapse
Affiliation(s)
- Paul Calès
- Laboratoire HIFIH, UPRES 3859, IFR 132, Université d'Angers, 49045 Angers Cedex, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
175
|
Palacios Pérez A, Salmerón Escobar J. Papel de la biopsia hepática en el diagnóstico y el control de la hepatitis C crónica. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 30:402-7. [PMID: 17692199 DOI: 10.1157/13108806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
For several years, liver biopsy has been the established gold standard for evaluating the status of liver disease in patients with chronic hepatitis C. Although this procedure continues to be recommended, current practice is changing for 2 main reasons: firstly, treatment is more effective and, secondly, biochemical and serological tests provide a great deal of information on disease progression. Pathologists can increase the importance and utility of liver biopsy in chronic hepatitis C, providing information not only on the stage of fibrosis and necroinflammatory activity but also on the grade of steatosis and iron accumulation, which are implicated in disease progression. Moreover, these specialists can identify other diseases, such as steatohepatitis and hereditary hemochromatosis. Nevertheless, the use of serological tests will reduce the indications for liver biopsy.
Collapse
Affiliation(s)
- Angel Palacios Pérez
- Unidad Clínica de Aparato Digestivo, Hospital Universitario San Cecilio, Granada, España.
| | | |
Collapse
|
176
|
Chan HLY, de Silva HJ, Leung NWY, Lim SG, Farrell GC. How should we manage patients with non-alcoholic fatty liver disease in 2007? J Gastroenterol Hepatol 2007; 22:801-8. [PMID: 17565632 DOI: 10.1111/j.1440-1746.2007.04977.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Evidence-based management guidelines for non-alcoholic fatty liver disease (NAFLD) are lacking in the Asia-Pacific region or elsewhere. This review reports the results of a systematic literature search and expert opinions. The Asia-Pacific Working Party on NAFLD (APWP-NAFLD) has generated practical recommendations on management of NAFLD in this region. NAFLD should be suspected when there are metabolic risk factors and/or characteristic changes on hepatic ultrasonography. Diagnosis by ultrasonography, assessment of liver function and complications, exclusion of other liver diseases and screening for metabolic syndrome comprise initial assessment. Liver biopsy should be considered when there is diagnostic uncertainty, for patients at risk of advanced fibrosis, for those enrolled in clinical trials and at laparoscopy for another purpose. Lifestyle measures such as dietary restrictions and increased physical activity (aerobic exercise) should be encouraged, although the best management strategy to achieve this has yet to be defined. Complications of metabolic syndrome should be screened for regularly. Use of statins to treat hypercholesterolemia is safe and recommended; frequent alanine aminotransferase (ALT) monitoring is not required. Obese patients who do not respond to lifestyle measures should be referred to centers specializing in obesity management; consideration should be given to bariatric surgery or gastric ballooning. The role of pharmacotherapy remains investigational and is not recommended for routine clinical practice. Non-alcoholic fatty liver disease should be recognized as part of the metabolic syndrome and managed in a multidisciplinary approach that addresses liver disease in the context of risk factors for diabetes and premature cardiovascular disease. Lifestyle changes are the first line and mainstay of management.
Collapse
Affiliation(s)
- Henry L-Y Chan
- Department of Medicine and Therapeutics and Institute of Digestive Disease, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China.
| | | | | | | | | |
Collapse
|
177
|
Debernardi-Venon W, Martini S, Biasi F, Vizio B, Termine A, Poli G, Brunello F, Alessandria C, Bonardi R, Saracco G, Rizzetto M, Marzano A. AT1 receptor antagonist Candesartan in selected cirrhotic patients: effect on portal pressure and liver fibrosis markers. J Hepatol 2007; 46:1026-33. [PMID: 17336417 DOI: 10.1016/j.jhep.2007.01.017] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2006] [Revised: 01/03/2007] [Accepted: 01/24/2007] [Indexed: 12/31/2022]
Abstract
BACKGROUND/AIMS The renin-angiotensin system plays an important role in hepatic fibrogenesis and in portal hypertension. To examine the long-term effects of Candesartan cilexetil, an angiotensin type 1 (AT1) receptor blocker, on portal-systemic haemodynamics and on liver fibrosis. METHODS Forty-seven compensated Child A and Child B (8) cirrhotic patients were randomly assigned to receive Candesartan cilexetil, 8 mg/d (N.24) and no treatment (N.23) for 1 year. Portal-systemic haemodynamic parameters, serological levels of procollagen (PIIINP), hyaluronic acid (HA) and transforming growth factor beta 1 (TGFbeta1) were assessed at baseline and after 12 months. RESULTS No patients discontinued or decreased the drug. The hepatic venous pressure gradient (HVPG) decreased significantly in treated patients (-8.4%+/-2.4) with a reduction >20% in 25% of cases vs+5.6%+/-2.9 in the untreated group. HA plasma levels decreased significantly in Candesartan treated patients in whom HVPG diminished and rose in untreated patients in whom HVPG increased. CONCLUSIONS In selected cirrhotic patients, pharmacological inhibition of the AT1 receptor is well tolerated and induced a mild reduction of portal pressure. This haemodynamic effect might be related to liver fibrogenesis activity.
Collapse
Affiliation(s)
- Wilma Debernardi-Venon
- Division of Gastroenterology and Hepatology, S Giovanni Battista Hospital, Turin, Italy.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
178
|
|
179
|
Bortolotti F, Guido M. Reversal of liver cirrhosis: a desirable clinical outcome and its pathogenic background. J Pediatr Gastroenterol Nutr 2007; 44:401-6. [PMID: 17414134 DOI: 10.1097/mpg.0b013e318032069a] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cirrhosis is the final stage of chronic liver damage of various etiologies. It used to be considered an irreversible lesion, but enormous advances in our understanding of hepatic cellular and molecular biology in the past 2 decades have challenged this view. There is now substantial evidence that cirrhosis can be a reversible process. This concept is supported by an increasing number of clinical reports showing the disappearance of cirrhotic lesions from liver biopsies taken from patients cured of their liver disease. The reversal of cirrhosis usually occurs in patients with short-lived liver disease, after the successful treatment of the underlying liver damage. Recently, however, we observed the spontaneous reversal of cirrhosis after the loss of hepatitis B viremia in 2 men, 21 and 28 years old, who had developed cirrhosis as young children. Several questions and controversial issues concerning the definition of advanced cirrhosis, the limitations of liver biopsy (eg, sampling, interpretation error), and the applicability of noninvasive methods to the assessment of fibrosis, are being addressed. Future prospects include the possibility of antifibrotic therapy to prevent fibrosis or favor its degradation.
Collapse
|
180
|
Poynard T, Halfon P, Castera L, Charlotte F, Le Bail B, Munteanu M, Messous D, Ratziu V, Benhamou Y, Bourlière M, De Ledinghen V. Variability of the area under the receiver operating characteristic curves in the diagnostic evaluation of liver fibrosis markers: impact of biopsy length and fragmentation. Aliment Pharmacol Ther 2007; 25:733-9. [PMID: 17311607 DOI: 10.1111/j.1365-2036.2007.03252.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The area under the receiver operating characteristic (ROC) curve is widely used as an estimate of the diagnostic value for fibrosis markers. Biopsy length and fragmentation are known as risk factors of false positive or false negative of biopsy but their quantitative impact on area under the receiver operating characteristic curve variability has not been assessed. AIM To assess these relationships to better compare the fibrosis markers. METHODS The area under the ROC curves of FibroTest for the diagnosis of fibrosis was estimated in patients with chronic hepatitis C using an integrated database including 1312 patients with FibroTest and biopsy. To take into account the biopsy length, we used two adjustment factors: one in which an observed area under the ROC curve could be adjusted according to the relative area under the receiver operating characteristic curve of a biopsy of a given length vs. the entire liver and one taking into account the prevalence of each fibrosis stage defining advanced and non-advanced fibrosis. RESULTS The mean biopsy length was smaller for cirrhosis (F4, 16 mm) vs. F3, (18 mm, P=0.01) and F0 (19 mm, P=0.01). The mean number of fragments was higher for cirrhosis (F4=4.1 fragments) vs. all the other stages (F0=1.9, F1=1.9, F2=1.9, F3=2.3; P<0.001 vs. F4). The FibroTest area under the ROC curves for the diagnosis of advanced fibrosis, adjusted for stages' prevalence, ranged from 0.80 to 0.98 depending on biopsy length and fragmentation, respectively. CONCLUSION The comparison of the area under the ROC curves of fibrosis markers should take into account the biopsy length and fragmentation.
Collapse
Affiliation(s)
- T Poynard
- APHP Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
181
|
Halfon P, Bacq Y, De Muret A, Penaranda G, Bourliere M, Ouzan D, Tran A, Botta D, Renou C, Bréchot MC, Degott C, Paradis V. Comparison of test performance profile for blood tests of liver fibrosis in chronic hepatitis C. J Hepatol 2007; 46:395-402. [PMID: 17156890 DOI: 10.1016/j.jhep.2006.09.020] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2006] [Revised: 08/28/2006] [Accepted: 09/11/2006] [Indexed: 12/15/2022]
Abstract
BACKGROUND/AIMS We evaluated the test performance profile (TPP) of blood tests of liver fibrosis. METHODS Three hundred and fifty-six patients with C chronic hepatitis were included in two centers. Metavir staging of liver specimens by two independent pathologists and the following tests were evaluated: Fibrotest (FT), APRI, FibroMeter (FM), and Hepascore (HS). RESULTS Metavir stages were: F0: 4%, F1: 55%, F2: 26%, F3: 11%, and F4: 4%. The AUROCs were not significantly different, respectively, FT, FM, APRI, HS: >or=F2: 0.79, 0.78, 0.76, >or=0.76; F3: 0.81, 0.85, 0.81, 0.81; and F4: 0.86, 0.94, 0.92, 0.89. The TPP relies on the paired comparison of blood-test misclassification based on liver specimen, e.g. FT vs FM, respectively: F0+1: 18 vs 28% (p=0.0003), >or=F2: 43 vs 31% (p=0.004). There was no center effect. CONCLUSIONS In those populations, the four blood tests had a similar performance for significant fibrosis (F>or=2), lying in the lower range of published results which is attributable to a low >or=F2 prevalence, and for >or=F3 and F4. However, FM and FT had performance profiles significantly different as a function of fibrosis stages or diagnostic target (fibrosis cut-off). This has to be considered during the interpretation process. Moreover, the performance should be reported with different diagnostic targets.
Collapse
Affiliation(s)
- Philippe Halfon
- Laboratoire Alphabio, 23 rue Friedland, 13006 Marseille, France.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
182
|
Castera L, Denis J, Babany G, Roudot-Thoraval F. Evolving practices of non-invasive markers of liver fibrosis in patients with chronic hepatitis C in France: time for new guidelines? J Hepatol 2007; 46:528-9; author reply 529-30. [PMID: 17239479 DOI: 10.1016/j.jhep.2006.12.002] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
183
|
Plebani M, Basso D. Non-invasive assessment of chronic liver and gastric diseases. Clin Chim Acta 2007; 381:39-49. [PMID: 17374528 DOI: 10.1016/j.cca.2007.02.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 02/13/2007] [Indexed: 02/06/2023]
Abstract
BACKGROUND In patients with both chronic liver diseases and dyspepsia there is the need for non-invasive, inexpensive and effective laboratory tests. These tests should not substitute but complement and integrate the information derived from invasive techniques such as liver biopsy and esofagogastroduodenoscopy. Natural history studies indicate that advanced fibrosis and cirrhosis develop in about 20%-40% of patients with chronic hepatitis B or C, and in a similar proportion of those with alcoholic or non-alcoholic steatohepatitis. In these patients, precise definition of the hepatic fibrosis stage is the most important parameter to assess the risk of disease progression and to decide for an immediate and appropriate antiviral therapy. METHODS Liver biopsy represents the gold standard for evaluating the presence, type and stage of liver fibrosis but a body of evidence has been accumulated to demonstrate the limitations of this technique, including inter- and intra-observer variations, sampling errors and variability. In recent years there has been an increasing interest in the possibility of identifying and describing liver fibrosis by using non-invasive, surrogate markers measurable in blood. Many studies have been dedicated to the evaluation of "direct" markers of fibrogenesis, while a second approach is based on the evaluation of single or combined biochemical parameters that reflect the stage of liver disease. Upper gastrointestinal symptoms are common in developed countries and this makes impossible the use of esofagogastroduodenoscopy in all patients with dyspepsia. The Maastricht 2-2000 Consensus meeting has suggested screening and treating Helicobacter pylori infection in dyspeptic patients in primary health care as the first line of therapy for newly onset dyspepsia. CONCLUSIONS Combination panels of biomarkers have been demonstrated to improve the accuracy of the single tests and with the use of algorithms based on sequential combination of non-invasive biomarkers a high diagnostic accuracy has been achieved for liver fibrosis. This, in turn, translates in a reduction by >50% in the need of taking liver biopsies. A biochemical panel which includes the measurement of serum pepsinogen I and II, gastrin G-17 and anti-H. pylori antibodies for patients with gastric disease, due to its high negative predictive value, appears to be a valuable approach to screen patients <55 years and with no alarm features, assuring safety and cost-effectiveness.
Collapse
Affiliation(s)
- Mario Plebani
- Department of Laboratory Medicine, University-Hospital of Padova, Italy.
| | | |
Collapse
|
184
|
Poynard T. Faut-il encore faire des biopsies du foie ? Rev Med Interne 2007; 28:67-70. [PMID: 17030487 DOI: 10.1016/j.revmed.2006.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2006] [Accepted: 09/05/2006] [Indexed: 01/06/2023]
|
185
|
Sebastiani G, Vario A, Guido M, Alberti A. Sequential algorithms combining non-invasive markers and biopsy for the assessment of liver fibrosis in chronic hepatitis B. World J Gastroenterol 2007; 13:525-31. [PMID: 17278217 PMCID: PMC4065973 DOI: 10.3748/wjg.v13.i4.525] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the performance of several non-invasive markers and of our recently proposed stepwise combination algorithms to diagnose significant fibrosis (F ≥ 2 by METAVIR) and cirrhosis (F4 by METAVIR) in chronic hepatitis B (CHB).
METHODS: One hundred and ten consecutive patients (80 males, 30 females, mean age: 42.6 ± 11.3) with CHB undergoing diagnostic liver biopsy were included. AST-to-Platelet ratio (APRI), Forns’ index, AST-to-ALT Ratio, Goteborg University Cirrhosis Index (GUCI), Hui’s model and Fibrotest were measured on the day of liver biopsy. The performance of these methods and of sequential algorithms combining Fibrotest, APRI and biopsy was defined by positive (PPV) and negative (NPV) predictive values, accuracy and area under the curve (AUC).
RESULTS: PPV for significant fibrosis was excellent (100%) with Forns and high (> 92%) with APRI, GUCI, Fibrotest and Hui. However, significant fibrosis could not be excluded by any marker (NPV < 65%). Fibrotest had the best PPV and NPV for cirrhosis (87% and 90%, respectively). Fibrotest showed the best AUC for both significant fibrosis and cirrhosis (0.85 and 0.76, respectively). Stepwise combination algorithms of APRI, Fibrotest and biopsy showed excellent performance (0.96 AUC, 100% NPV) for significant fibrosis and 0.95 AUC, 98% NPV for cirrhosis, with 50%-80% reduced need for liver biopsy.
CONCLUSION: In CHB sequential combination of APRI, Fibrotest and liver biopsy greatly improves the diagnostic performance of the single non-invasive markers. Need for liver biopsy is reduced by 50%-80% but cannot be completely avoided. Non-invasive markers and biopsy should be considered as agonists and not antagonists towards the common goal of estimating liver fibrosis.
Collapse
Affiliation(s)
- Giada Sebastiani
- Department of Clinical and Experimental Medicine, University of Padova, Padova 35100, Italy
| | | | | | | |
Collapse
|
186
|
Ratziu V, Giral P, Munteanu M, Messous D, Mercadier A, Bernard M, Morra R, Imbert-Bismut F, Bruckert E, Poynard T. Screening for liver disease using non-invasive biomarkers (FibroTest, SteatoTest and NashTest) in patients with hyperlipidaemia. Aliment Pharmacol Ther 2007; 25:207-18. [PMID: 17229244 DOI: 10.1111/j.1365-2036.2006.03182.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Mortality related to complications of cirrhosis is increasing in patients with insulin-resistance factors. Hyperlipidaemic patients have multiple risk factors of insulin resistance. It is impossible to perform liver biopsy in such a large number of hyperlipidaemic patients to identify patients with advanced liver fibrosis or with steatohepatitis (non-alcoholic steatohepatitis, NASH). AIMS To use the non-invasive biomarkers, FibroTest (FT), SteatoTest and NashTest, and to assess the prevalence of advanced liver disease in a large population of hyperlipidaemic patients. METHODS A consecutive cohort of hyperlipidaemic patients was followed prospectively in a lipid centre and the sera were analysed retrospectively. RESULTS A total of 2834 subjects were included: 1909 hyperlipidaemic patients and 925 blood donors (BD). Advanced fibrosis was identified by FT in 53/1909 (2.8%) hyperlipidaemic patients vs. 0/925 BD (0%) (P < 0.0001); advanced steatosis in 569/1893 hyperlipidaemic patients (30.1%) vs. 8/164 (4.9%) BD (P < 0.0001) and NASH in 132/1893 (7%) vs. 0/164 (0%), respectively (P < 0.0001). There was a highly significant and linear association between the number of metabolic syndrome factors and liver disease prevalence - the highest being for type 2 diabetics: advanced steatosis 66%, NASH 24% and advanced fibrosis 6%. CONCLUSIONS The prevalence of fibrosis, steatosis and NASH in hyperlipidaemic patients appears to be high (3%, 30% and 7%, respectively). Biomarkers could be useful for screening of advanced fibrosis and NASH in patients with several metabolic syndrome factors, to prevent liver mortality.
Collapse
Affiliation(s)
- V Ratziu
- APHP Hépatologie GHPS, Paris, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|